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Full text of "United States Navy Medical News Letter Vol. 32 No. 5, 5 September 1958"

NavMed 369 




UNITED STATES NAVY 1 

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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 32 



Friday, 5 September 1958 



No. 5 



TABLE OF CONTENTS 



Historical Fund of the Navy Medical Departrrjent 

Prevention and Control of Staphylococcus Infections in Hospitals 

Racial Incidence of Coronary Vascular Disease 

Intrapalmonary Hematoma 

Syphilis Today 

Cancer of Rectum and Colon 

Early Exploration of Vascular Injuries 

Prosthetic Restorations Associated with Abnormal Jaw Relations 

Parathyroid Crisis 

Treatment of Idiopathic Thrombocytopenic Purpura 

Hazards in the Handling of Hydrogen Peroxide 

Occupational Aspects of Habituating Drugs 

Mouth-to -Mouth Versus Manual Artificial Respiration 

Atypical Heat Stroke 

New Film Release 

From the Note Book 

Poliomyelitis Vaccine (BuMed Inst. 6230. 8C) 

Pest Control at Naval Hospitals (BuMed Inst. 6250, 6) 

DENTAL SECTION 

NDS Graduate Courses 32 Training in Casualty Treatment 

Dental Appointnnent Card 33 

RESERVE SECTION 
Credit for Attending Meetings .... 33 Pay Scale for Junior Officers . . 
Naval War College Publication . . 3 3 Synnposia in Special Weapons. . . 

PREVENTIVE MEDICINE SECTION 



Foods in Vending Machines 35 

Travel Iramvinization 36 



Advances in Study of VD . . 
Atypical Acid-Fast Bacilli 



2 

3 
7 
10 
12 
15 
18 
19 
21 
22 
25 
26 
26 
27 
28 
29 
31 
31 

32 



34 
34 

37 

38 




Medical News Letter, Vol. 32, No. 5 



HISTORICAJL FUND 
of the 
NAVY MEDICAL DEPARTMENT 



A committee has been formed with representation from the Medical 
Corps, Dental Corps, Medical Service Corps, Nurse Corps, and 
Hospital Corps for the purpose of creating a fund to be used for the 
collection and maintenance of itenns of historical interest to the Medical 
Department. Such items will include, but will not be limited to, por- 
traints, nnemorials, etc., designed to perpetuate the memory of dis- 
tinguished members of the Navy Medical Department. These memorials 
will be displayed in the Bureau of Medicine and Surgery and at the 
National Naval Medical Center. Medical Department officers, active 
and inactive, are invited to make small contributions to the fund. It is 
emphasized that all donations must be on a strictly voluntary basis. 
Funds received will be deposited in a Washington, D C. bank to the 
credit of the Navy Medical Department Historical Fund, and will be 
expended only as approved by the Committee or its successor and for 
the objectives stated. 

It is anticipated that an historical committee will be organized at each 
of our medical activities. If you desire to contribute please do so 
through your local historical committee or send your check direct, 
payable to Navy Medical Department Historical Fund, and mail to: 

Treasurer, N. M. D, Historical Fund 
Bureau of Medicine and Surgery {Code 14) 
Department of the Navy 
vVashington 25, D C. 



Committee 

F. P. GILMORE, Rear Admiral (MC) USN, Chairman 
R. W. MALONE, Rear Admiral (DC) USN 
W. C. CALKINS, Captain (MSC) USN 
R. A. HOUGHTON, Captain (NC) USN 
T.J. HICKEY, Secretary-Treasurer 



Medical News Letter, Vol. 32, No. 5 



Prevention and Control of Staphylococciis 
Infections in Hospitals 

Knowledge of the Current Situation 

It is clear that throughout the world, in spite of the enormous success 
of antibiotics (and, as will be mentioned below, to some extent because of 
this success) there remains an important problem of infections, a problem 
of special significance for hospitals. This report is concerned with such 
infections, particularly those caused by the coagulase -producing strains of 
staphylococcus aureus hemolyticus. The most obvious examples are impetigo 
and more severe infections in children, puerperal mastitis in recently deliver- 
ed women, burn and postoperative wound infections, and pneumonia in debil- 
itated patients. The staphylococcus may also be responsible for osteomye- 
litis, nneningitis, septicemias, empyemas, boils and abscesses, otitis media, 
paronchiae, et cetera. 

Disease-producing staphylococci frequently implant in the nasopharynx 
without overt disease, thus producing carriers. Indeed, the staphylococcus 
carrier-rate is a good index of the level of contamination of the environment. 
Many hospitals have a serious problem with staphylococcus infections, 
and all hospitals have a potential problem. Information is inadequate as to 
the incidence of staphylococcus infections which are acquired in hospitals, 
but there is evidence that the number of such infections is increasing. 

There appear to be innumerable strains of staphylococcus capable of 
producing infections. Many of these staphylococci are susceptible to anti- 
biotics. Some are not. Infections with antibiotic -resistant staphylococci 
constitute the main difficulty. Hospitals are clearly the reservoir of most 
antibiotic -resistant strains. Strains from the connmvinity at large are pre- 
dominantly sensitive to antibiotics. The strains carried by patients on 
admission are less frequently resistant than strains which are acquired in 
hospitals. Patients who acquire these infections in the hospital are poten- 
tial spreaders of resistant strains to the commiinity after discharge. One 
of the major factors in the current situation is the widespread use of anti- 
biotics which eliminates susceptible strains of staphylococcus and leave 
uncontrolled the resistant strains. 

Certain factors frequently found in hospitalization appear to make 
patients more likely to acquire such staphylococcus infections; (a) routine 
indiscriminate use of antibiotics, especially for "prophylaxis"; (b) long 
hospital stay; (c) contact, direct and indirect, with infected hospital patients, 
staff members, or personnel; (d) crowding and inadequacy of facilities; (e) 
prolonged operative procedures; (f) prolonged use of continuous parenteral 
therapy through venipunctures or indwelling plastic tubing. 

Certain factors in the host (patient) appear to increase susceptibility 
to infection: (a) treatment with adrenocortical steroids; (b) physical debility; 
(c) chronic disease; (d) prematurity; (e) diabetes; (f) bed sores; (g) open 
wounds or breaks in the skin; (h) chronic pulmonary disease. 



4 Medical News Letter, Vol. 32, No. 5 



Danger of infection seems to be especially great from direct exposure 
to people infected with the staphylococcus, although exposure to the sanne 
organisnns in, or^on, contaminated equipment, supplies, dressings, air, 
dust, wall or floor surfaces, linens, et cetera, nnay be equally as impor- 
tant. The physician, nurse, or other attendant with a boil, paronychia, 
abscess, or nasopharyngeal infection with a virulent strain is particularly 
hazardous. 

Ileconr^nnendations 

All hospitals should establish Comimittees on Infections, to devote 
particular attention to infections which are acquired in hospitals so they nnay 
be reduced to the lowest possible minimum. 

A. It is suggested that the Committee on Infections include, where 
possible, a bacteriologist, a pediatrician, a surgeon, an internist, a nurse, 
and a hospital administrator. The local health officer should be urged to 
serve as a consultant to the committee. The committee should report per- 
iodically to the executive connmittee of the nnedical staff. 

B. The functions of the Committee on Infections should include at 
least the following: 

1. To establish a system of reporting infections among patients and 
personnel, such a system being essential to a proper understanding of 
infections which are acquired in hospitals. The committee should have 
access to all reports of infections anywhere in the hospital. 

2. To keep records of infections as a basis for the study of their 
sources and for recommendations regarding remedial measures. 

3. To distinguish to the best of its ability between infections acquired 
in the hospital and those acquired outside. 

4. To review the hospital's bacteriological services to make sure 
that such services are of high quality and are accessible either in the 
hospital itself or in an outside laboratory. Bacteriophage typing, if not 
available in the hospital, may be sought as needed through official local 
and state health agencies. 

5. To review aseptic techniques employed in operating roomis, deliv- 
ery rooms, nurseries, and in the treatment of all patients with infections 
and, if indicated, to recommend methods to improve these techniques 
and their enforcement. 

6. To make vigorous efforts to reduce to the nninimum consistent with 
adequate patient care: 

(a) Use of antibiotics, especially as "prophylaxis" in clean, 
elective surgery 

(b) Treatment with adrenocortical steroids 

7. To undertake an educational program to convince medical staff 
and hospital employees of the importance of reporting to responsible 



Medical News Letter, Vol. 32, No. 5 



authorities when they have skin infections, boils, acute upper respiratory 
infections, and the like. 

8. To establish techniques for discovering infections which do not 
become manifest until after discharge from the hospital, it being known 
that such infections are often overlooked because they may not be appar- 
ent until several weeks after the patient has left the hospital. Two ap- 
proaches to discovering such infections are suggested: 

(a) An attempt to trace the source of any infection with which a 
patient may be admitted. For example, if an infant is admitted with 
staphylococcal pneumonia or a recently delivered mother vvith mastitis, 
the hospital where delivery occurred should be determined and infornned 
of the infection so that it can seek possible sources of infection. 

(b) Periodic telephone polls on a random sample of discharged 
patients (particularly recently delivered nnothers, newborns, and 
postoperative patients) to ascertain their state of health and, in case 
of any indication of infection, to follow them up. Such surveys have 
proved quite sioiple and quite valuable. A detailed account of the 
nnethod is given by Ravenholt and others in the October 1956 issue 

of the Annerican Journal of Public Health. 

Hospital administration should undertake the following measures to 
assist in the control of infections: 

A. Diligent maintenance of the general cleanliness of all areas in the 
hospital, not simply in those associated with operating rooms, delivery 
roonns, and nurseries. Other possible sources, such as dust, air pollution 
(special attention should be given to ventilating and air-conditioning systems 
and their filters), and floors must also be considered as potentially impor- 
tant factors in the spread of infection. There should be regular inspections 
of the hospital for general cleanliness. 

B. Special studies among staff and personnel to uncover silent car- 
riers of staphylococcus, especially in epidemic situations accompanied by 
repeated cases traceable to the same organism. 

C. Appropriate measures for the treatment of all carriers who per- 
sistently show heavy growth of epidemic strains of staphylococcus in naso- 
pharyngeal cultures or who are identified by epidemiological evidence. 

D. Transfer of such carriers and personnel with skin infections, boils, 
acute upper respiratory infections, and the like from locations, such as 
operating rooms, delivery rooms, food-handling positions, and nurseries 

to other duty stations in the hospital. Usually such transfers have proved 
to be sufficient to control the problem, but occasionally, leave of absence 
for a persistent carrier has been necessary. 

Hospitals should initiate or participate in community programs to 
control infection through cooperation with other hospitals, local medical 
societies, local health departments, and other groups. 



Medical News Letter, Vol. 3Z, No. 5 



General Comment 

Occasionally, an entire hospital, a whole community, or a large area 
seems to become subject to an epidemic strain of staphylococcus, v/hy this 
occurs is not known. Its occurrence, however, points up the need for more 
general recognition and study of staphylococcus infections. 

Among the agencies fromi which consultation and assistance concern- 
ing infection problems may be sought are the following: 

(a) The American Hospital Association, the American College of 
Surgeons, and the American Academy of Pediatrics (especially for 
newborn infants) which will furnish upon request the names of suit- 
able consultants. 

(b) LfOcal and state health departments which, in many instances, 
have experts on their staffs. 

(c) The Conrimunicable Disease Center of the U.S. Public Health 
Service, Atlanta, Ga. , whose assistance may be obtained through 
local and state health departments. 

Valuable background information and discussion about the infection 
problem can be found in: 

(a) Conference on staphylococcal infections. (Syn^posium) Journal 
of the American Medical Association. 166: 1177-1203, March 8, 1958; 
(Editorial p. 1205) " 

(b) Observations relative to the nature and control of epidennic 
staphylococcal disease, F.H. Vfentworth and others. American 
Journal of Public Health. 4£: 287-298, March 1958. 

(c) New York (State) Department of Health Guide for the preven- 
tion and control of infections in hospitals. Albany; 56p illust. 1957. 

(d) New York Academy of Science. Staphylococcal infections; a 
symposium. The New York Academy, 1956. bl^-ZAb-p. illust. , tables. 
(Annals of the New York Academy of Sciences, 65: 57-246) 

(e) The problems of postoperative wound infection and its signifi- 
cance. W.A. Altemeier. Annals of Surgery. 147:770, 1958. 



The National Library of Medicine has compiled a lengthy bibliography 
on staphylococcal infection, which, it is hoped, may be of value to both pri- 
vate and public health physicians who are engaged in combating the increased 
incidence of antibiotic resistant staphylococcal infection in the home, com- 
munity, and hospital. The bibliography will be sent at no cost on request to: 

National Library of Medicine 
7th St. and Independence Ave. , S. vV. 
vVashington 25, D. C. 



Medical News Letter, Vol. 32, No. 5 



{Crosby, E. L. , Prevention and Control of Staphylococcus Infections in 
Hospitals: Military Medicine, 123: 146-149, August 1958) 

(This bulletin was prepared by the Council on Professional Practice's Com- 
mittee on Infections within Hospitals, consisting of: Dean A. Clark, M. D. , 
Chairman; William A, Altemeier, M.D. ; C. P. Cardwell Jr. ; James P. 
Dixon Jr. M.D. ; Maxwell Finland, M. D. ; Horace L, Hodes, M.D. ; 
Martha Johnson, R. N. ; and Alexander D. Langmuir, M. D. , in consultation 
with Kenneth B. Babcock, M.D. of the Joint Commission on Accreditation 
of Hospitals; V\/illiann H. Steward, M.D. of the Public Health Service, and 
others.) 

*^ 3!c jtc ^ sEe 
■TT" "T* 'T* 'T' nP 

Racial Incidence of Coronary Vascular Disease 

The etiology of coronary vascular disease — by which is meant coro- 
nary atheronna and coronary thrombosis — is as yet unknown. Of the many 
factors implicated, geographic and climatic environment cannot in any way 
be responsible. In Cape Town, there is a multiracial community living 
in the same climate, with each race, in the main, adhering to its own tra- 
ditional customs, particularly as regards diet, and yet the incidence of 
coronary vascular disease differs remarkably in each group. 

Of the three racial groups, the Whites are mainly descendants of 
immigrants from Great Britain and Holland and are economically privileged. 
Their number has gradually increased by natural rise in births, by drift 
from the country to the city, and by immigration from Europe. Even the 
patients who attend the public hospital (Groote Schuur Hospital), although 
representing the poorer section of the White community, earn considerably 
more than the non- White population. 

The Cape Colored community originated mainly from European, Hot- 
tentot, and Malay stock, the Hottentot comprising the original indigenous 
population of the Cape. Only within the last few decades has any Bantu been 
added. Included in this group is a section of Cape Malays (of Moslem faith) 
who are said to be relatively pure descendants of imported Malays, From 
the socioecononnic point of view, the Cape Colored population is intermed- 
iate between the Whites and the Bantu. They connpete in the skilled and 
unskilled labor market, and, compared with the Bantu, have a far greater 
proportion of professional men, although far fewer than the Whites. Like 
the Whites, they are relatively stable and migrate rarely. They have in- 
creased considerably in numbers both by natural increase in birth rate 
which is higher than that of the Whites and by drift from the country to the 
city. 



Medical News Letter, Vol. 3Z, No. 5 



The Bantu, as a rule, are lowest in the socioeconomic scale, provid- 
ing the unskilled and heavy manual labor. Migrating often from the rural 
areas, their stay in the city is temporary — from one-half to two years — 
during which time they attempt to save money to meet their own needs and 
the needs of their hon:es in the Reserves. However, there are some who 
have lived most of their lives in the city or have been born there. These 
approach closest to the Whites in education, employment, and diet. Few, 
however, have as yet reached the professional class. Their numbers have 
tended to fluctuate and they have been actively encouraged to return to the 
Reserves. Their birth rate is high, but the immigration of their womenfolk 
is definitely discouraged. 

During the period under survey, the electrocardiographic service of 
the Cardiac Clinic included all inpatients and outpatients attending Groote 
Schuur Hospital, and the 44 inpatient teaching beds of the New Somerset 
Hospital, Inasmuch as over 99% of the 21, 582 records were interpreted by 
the author, any errors in electrocardiographic interpretation were constant 
in all racial groups. The same physicians and surgeons see patients of all 
races and the facilities for obtaining electrocardiographic investigation are 
equal. The data obtained, therefore, reflect the relative incidence of the 
disease as it occurs in the Groote Schuur Hospital. 

Almost twice as many electrocardiograms were requested for vVhite 
as for Cape Colored patients (7232 :4498), although the hospital and general 
populations were approximately equal. This suggests that attention is drawn 
to the heart more often in the White than in the Cape Colored patients and 
the chief reason for this is the greater incidence of coronary vascular dis- 
ease in the Whites. 

Both in Whites and Cape Colored, over 90% of the cases occurred in 
patients aged 40 years and older. The peak incidence in Whites was between 
the ages of 50 and 69 years, the maximum number of cases occurring in the 
decade 50-59. In the Cape Colored, the peak decade was similarly 50-59, 
but more cases occurred between the ages of 40 and 49 than between 60 and 69. 

The effect of sex on the incidence of infarction is well borne out in 
Tables. In Whites, during the reproductive cycle (20-49) the incidence in 
males is four times that of females — when all cases are considered — and 
up to six times when cases showing infarction (rigid criteria) are analyzed. 
In the Cape Colored, the figures are two to one and four to one, respectively. 
The difference in sex incidence is even nnore striking in the Bantu. No case 
has yet been noted in a female Bantu in Groote Schuur Hospital, although 
the figures are too small to have statistical significance. With advancing 
age, there is a tendency for females to catch up with the males, although 
at no age in the present series have the two sexes been equal. These 
figures are in accordance with data published elsewhere. Thus, figures 
from Minnesota show a far greater severity of atherosclerosis in men than 
in women. The severity of coronary sclerosis in women increases steadily 



Medical News Letter, Vol. 32, No. 5 9 



from the fourth to the eighth decade, leveling off in the ninth decade. In 
men, leveling off takes place after the sixth decade. At all ages, athero- 
sclerosis is far comtTioner in men than in v^omen, although this is most 
marked between the ages of 50 and 59. 

The results obtained in this study show that there is a considerable 
difference in the incidence of coronary vascular disease in the three racial 
groups. The Whites far outnumber the Bantu, and the Cape Colored fall 
between the two groups. Whether this is related to the difference in dietary 
habits of the three racial groups, however, remains to be proved. Yudkin 
has recently critically analyzed the evidence. That nnultiple causes are 
involved appears clear, and this indicates factors, such as overconsumption 
of food, reduced physical exercise, smoking, nervous strain, tension, and 
type of occupation. Friedman and Rosenman analyzed the dietary intake of 
fat in a group of American men and women and reviewed the data relating 
to the relative immunity of the American wornen from coronary vascular 
disease. Clearly, the factor of sex plays a most important part in the patho- 
genesis of the disease, and probably this is related to some defect of meta- 
bolism in the nnale. The tremendous importance of sex is borne out by the 
author's figures which show a consistently higher occurrence in nnales of 
all races. Lastly, the role played by intravascular thrombosis in the etio- 
logy of atheroma is not yet fully understood. As yet, no information exists 
on the influence of this factor on the incidence of this disease in the three 
racial groups studied. 

It can be definitely stated that a considerable difference in incidence 
of coronary vascular disease exists in the three racial groups of Cape Town. 
No difference in the anatomy of the heart and coronary circulation or in 
blood coagulation has yet been demonstrated. Certain imponderable factors, 
such as stress and strain, emotional and physical, are difficult to assess or 
measure. A parallel difference in diet, however, particularly the amount 
of animal fat consumed, has also been shown to exist. Whether the two are 
causally related still remains to be proved. (Schrire, V. , The Racial 
Incidence of Heart Disease at Groote Schuur Hospital, Cape Town. Part I. 
Coronary Vascular Disease: Am. Heart J. , 56: 280-288, August 1958) 

****** 
Change of Address 

Please forward requests for change of address for the News Letter to: 
Conrjmanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses. 

>);;}; j[: :i{: s[: jj: 



10 Medical News Letter, Vol. 32, No. 5 



Intrapulmonary Hematoma 

in recent years, the problem of solitary circumscribed pulmonary 
nodules has attracted much attention in the nnedical literature. The difficul- 
ties involved in establishing an accurate diagnosis in cases of this kind are 
vvell recognized and are usually resolved by resort to exploratory thoraco- 
tomy and excision of the lesion. That this approach to the problem is ration- 
al and well founded is amply substantiated by the many excellent reviews on 
the subject which have established an incidence of nnalignancy in such cases 
varying from approximately 7 to 74% and averaging about 37%. The major 
portion of this group is comprised of primary bronchogenic carcinoma, 
while metastatic tunnors and other primary malignant diseases, such as 
bronchial adenoma, sarcoma, or lymphoblastoma make up a much smaller 
component. Nonmalignant lesions which most commonly present as isolated 
pulmonary nodules are tuberculomas, granulomas of nonspecific origin, 
hannartomas, histoplasmomas, and coccidioidomas. In addition to the above 
disorders, there is a great variety of less common and even rare conditions 
which may assume the form of "coin" lesions and with which the physician 
must be familiar if he is even to consider the correct diagnosis prior to 
surgical exploration of the chest. To mention some of these diseases — 
chronic organized pneumonitis, lung abscess, bronchogenic cyst, pleural 
me sothelionia, lipoid granuloma, neurofibroma, pulmonary infarct, encap- 
sulated pleural effusion or empyema, blastomycosis, cryptococcosis, 
hemangioma, hydatid cyst, fibrin body, and brucellosis may all appear as 
solitary circumscribed pulmonary nodules. 

This report adds to the list another condition which hitherto has re- 
ceived little attention, that is, intrapulmonary hematoma. Persistent, cir- 
cumscribed, intrapulnnonary hematomas must be either extremely rare in 
occurrence or generally unrecognized if one can judge from the few cases 
which have appeared in the literature. 

Although a number of authors have briefly described or referred to 
hennatoma formation in the lung, the roentgenographic changes produced by 
these lesions have been variously indicated as "spindle-shaped" or "ill- 
defined" and have not presented the sharply circumscribed, round, or oval 
appearance of the so-called "coin" lesion. Only the three cases reported 
by Salyer, Blake, and Forsee and the single case mentioned by Condon fail 
into this category. 

Results of traunna to the lung or pleura are usually easily recognized. 
A clear-cut history of injury, either penetrating or nonpenetrating, is seen 
in the form of rib fractures or contusions of the chest wall. If these findings 
are further associated with the typical roentgenographic appearance of henno- 
thorax, pneumothorax, or pneumohemothorax, it is easy to ascertain that 
injury to the pleura has occurred. 

Violence to the chest may also injure the pulmonary parenchyma 
without apparent evidence of pleural perforation. Roentgenographic findings 



Medical News Letter, Vol. 32, No. 5 11 



are less characteristic in such cases, but usually reflect the results of 
hemorrhage and edema within the lung substance. Areas of diffuse infil- 
tration or consolidation are seen, sometimes associated with an atelectatic 
component resulting from intrabronchial bleeding. The nature of these find- 
ings is further clarified by their tendency toward prompt regression during 
a period of a week or more. 

Where the intrapulmonary bleeding is localized and becomes sharply 
circumscribed into the form of a solitary hematoma, the diagnosis becomes 
less certain because this type of lesion may be clinically indistinguishable 
fron^ a primary bronchogenic carcinoma or any other condition which can 
assume the appearance of a "coin" lesion. In spite of a history of trauma, 
the presence of rib fractures or evidence of other injury to the chest, the 
physician is now confronted by an indeterminate pulmonary lesion, the exact 
nature of which can be established only by resort to exploratory thoracotomy. 
This was the situation in the cases reported by Salyer et al, and in the patient 
described by the authors. 

Because all of the sharply circumscribed intrapulmonary hematomas 
thus far reported have been surgically excised, little is known of their ulti- 
mate fate. In describing poorly defined hematonnas of the lung secondary 
to blast or nonpenetrating injury, McGrigor and Samuel state that resolution 
of the lesion may take as long as 6 to 8 weeks. Blair indicates a sinnilar 
course for hematomas of this type. In 1950, Welkind reported what was 
probably the first case of a sharply circumscribed pulmonary hematoma to 
appear in the miedical literature. The lesion was described as a "tumor- 
like shadow consisting of two spindle masses which fused at their axillary 
ends. " Resolution gradually took place over a period of 13 months, leaving 
two persistent linear scars. The author believed it to be "inconceivable that 
a simple hematoma would take 13 months completely to re sorb, " and pos- 
tulated that the lesion was associated with an element of infarction or that 
it was possible "some sort of thick capsule formed around the clotted blood, 
retarding the resolution. " 

As Welkind postulated, it is undoubtedly the cyst forination which 
accounts for the persistent nature of these lesions. Just how long a well 
organized encapsulated hematoma might remain unchanged within the lung 
is still a matter for speculation. 

Pulmonary hematomas of this type appear to be distinctly rare, but 
should be considered in the differential diagnosis of isolated discrete 
nodules of the lung, particularly if there is a prior history of chest trauma 
or evidence of rib fracture. Even though the nature of such a lesion is sus- 
pected, exploratory thoracotomy will usually be required in order to estab- 
lish the correct diagnosis. (Buechner, H. A, , Thompson, J. , Circumscribed 
Intrapulmonary Hematoma Presenting as a "Coin" Lesion: Dis Chest, 
XXXIV : 42-52, July 1958) 



12 Medical News Letter, Vol. 32, No. 5 



Syphilis Today 

Suspension of publication of good American sources of information on 
syphilis and the other venereal diseases and the dropping of "syphiiology" 
fron:i the titles of departments of dermatology in many medical schools and • 
from the names of well established societies are all signs of the times. 

Undoubtedly, penicillin therapy has played no small role in this de- 
cline of syphilis and the interest in it as a disease. It is contended that, 
because penicillin treatnnent is so safe and effective, the fine points of 
diagnosis and differentiation of syphilis fronn other diseases may be dis- 
pensed with and that no harm will come from the wholesale — almost indis- 
crinninate — use of the drug. Already, the effects of this philosophy are 
becoming apparent. Penicillin is capable of causing reactions, even fatal 
ones. Certain patients with syphilis actually go through various clinics, 
including dermatology, without the nature of their disease being suspected 
for some tinne. The result also is that nnedical students have no opportunity 
to learn about the diagnosis of this disease. Failure to employ serologic 
testa for syphilis leads to loss of diagnostic advantage in early lupus ery- 
thematosus. In addition, here and there, actual increases in the syphilis 
population are noted, while, in general, there is a definite sustained reduc- 
tion in the incidence of this infection up to a certain point. Although many 
advances have been made, there are still numerous xmanswered problems 
connected vvith syphilis as well as with the other treponemal diseases. Des- 
pite progress made in reducing the naortality from syphilis, it still remains 
one of the more important causes of death among infectious processes. 

In spite of all that has been said, syphilis must still be contended with. 
In this discussion, the author indicates that syphilis is recurring in many 
places all over the world, although the net result is still to the good. Because 
penicillin has made it possible for the first time to cure syphilis, the attitude 
toward this problem has been somewhat changed. Also, the question of re- 
lapse and reinfection needs further elucidation. Thus, 13 years after the 
introduction of penicillin, the author discusses briefly: What has penicillin 
done? Is syphilis dead? What is the evidence for or against this? What 
are still problems in syphilis and what is the future of syphilis? 

The passing of the diagnosis and management of syphilis from the 
hands of a few — usually dermatologists — to physicians in general is inore 
apparent now than in the past. This trend carries with it an obligation of 
which the practitioner may well be cognizant. This includes careful exam- 
ination before therapy and careful post-treatment follow-up study, as well 
as case finding, if the best interests of the public health are to be served. 

Rosahn's study of the adverse influence of syphilis on longevity has 
given practitioners something to think about. All of this did not deter organ- 
izations from manifesting a lessened interest in syphilis or the other vener- 
eal diseases to the point that a belief swept the community that these diseases 



Medical News Letter, Vol. 32, No. 5 13 



no longer constitute a danger to society or a challenge to medicine. This 
was due to publicity, to a steady decline in the early manifestations of the 
once fulminating disease syphilis, and to the effects of therapy with arsen- 
icals and penicillin which, in turn, have done much to modify the disease 
and to set up further waves of optinnism. It would be unrealistic to predict 
the swift eradication of a disease as complex in its clinical and epidemio- 
logical aspects as syphilis. Yet, the statement "the long-term trends in the 
incidence of syphilis have not been altered by antibiotic therapy" would be 
alnnost equally unrealistic. 

Syphilis (and the other treponematoses) still are an important world 
public health problem. In 1955, it was estimated that there were about 
20, 000, 000 persons with syphilis in the world and that in special areas of 
certain countries as many as 80% of the population were probably affected. 
There was wide variation within countries in the prevalence of venereal 
disease. In Africa as a whole, it ranged from 14. 1% to 32.9%; in southeast 
Asia, from 0. 6% to 31%; in Egypt, from 0. 29% to 27%; in India, from less 
than 1% to 50%. 

In 1955, Rein regretted the lowered index of suspicion on the part of 
physicians who believed that venereal disease may be eradicated if proper 
measures were taken. Already, in 1955, in some areas of the United States, 
the clinical incidence of early infectious syphilis was no longer falling; 
in 1956, the Third Annual Joint Statement of the Status of Venereal Disease 
Control in the United States continued to urge increased Federal support of 
state and local venereal disease control programs, increased attention on 
the part of the Federal Government to venereal disease problems of migrant 
labor, collection of information and development of a program to prevent 
venereal disease annong teenagers, and Congressional appropriation of 
$5,000,000 for Federal assistance to states. 

At present, there still seem to be conflicting data with respect to the 
incidence of syphilis and the need for its control, one group reporting a 
falling trend and the other nnaintaining that syphilis is still here. In the past 
year, however, certain evidence indicates that syphilis has not been conquered. 
For example, in New York City, Rosenthal and Vandow indicated that, al- 
though the number of newly reported cases per 100, 000 population in 1954 
was about half of what it was in 1938, there were still about 20,000 newly 
reported cases in 1954. In fact, in the United States as a whole, 156,000 
new cases of syphilis were reported in 1953. 

Although it is true that the number of cases of congenital syphilis has 
significantly decreased, there has been a much nnore gradual fall in the 
incidence rates of early, late latent, and late syphilis. Further reductions 
in incidence of venereal disease will be difficult to achieve in an area such 
as New York City which is not only a focal point for traffic from all parts of 
the United States, but also is a global seaport and airport. Population move- 
ment from within the country combined with increasing international traffic 



14 Medical News Lietter, Vol. 32, No. 5 



constitute problems beyond any local public health control. These and other 
factors peculiar to a large metropolis indicate the need for maintaining a 
vigorous program for the continued control of venereal disease. 

Porter clainns that, in the State of Delaware, there has been an increase 
in the reports of new infections since 1952; that there must still be a sizable 
reservoir of cases which have not been detected or adequately treated. He 
believes that the battle against syphilis is not yet won. Seine increases in 
the incidence of syphilis have been noted in Ohio by DeOreo, and in New 
Jersey — especially in the teenagers. Parker of Nebraska, while recogniz- 
ing the decreased total incidence of syphilis, feels that the venereal disease 
problem has not been solved. He, too, calls attention to the increase in 
venereal diseases an^ong teenagers. Dennie believes that both the medical 
profession and the laity must be reacquainted with the fact that syphilitic 
disease is still a fornnidable factor in the list of contagious diseases in this 
country. Millions of people are still suffering from this disease. New cases 
run into the hundreds of thousands each year. In order to control syphilis 
and gradually eliminate it as an innportant factor in the health problems 
of the United States, a systenn of education must be carried on, not only 
continuously, but more intensely. 

Fiumara, Appel, Hill, and Mescon who have reviewed the present 
status of syphilis and its management reiterate that the venereal diseases 
are again on the rise and that syphilis is still a nationwide problem. Thia 
means that a reservoir of infectious syphilis exists in most communities. 
There is also a residuum of noninfectious syphilis. All of these data indi- 
cate that syphilis will be a serious medical problem for many years. In 
Pennsylvania, a 13. 4% increase in the number of new cases of venereal 
disease was reported for the State in 1956 as compared with 1955. 

An editorial in the New England Journal of Medicine points out that, 
here and there, small epidemics of syphilis were reported during the fiscal 
year July 1, 1955 to March 31, 1956. More cases of primary and secondary 
syphilis were reported in the United States than in the corresponding period 
of the previous fiscal year. The indications are that the control effort is 
unable to cope with the national problem of syphilis. Because the increases 
in both sexes were found in 20 widely scattered states among both Negroes 
and whites, and were characteristic of both private and public treatment 
sources, thay may well forecast large increases in infectious syphilis 
throughout the nation. Massachusetts — an area of low syphilis population — 
had a 20% increase in syphilis in 1951, principally in the late and latent 
phases. These reported rates continued v^/itho^t significant changes at this 
elevated level until the present fiscal year when another and sharper increase 
was noted. There was a 59% increase in primary and secondary syphilis and 
a 14% increase in early latent cases over the previous year, making an over 
all increase of 30% in infectious syphilis. Late latent and late syphilis in- 
creased by 17%. The years of complacency are bearing bitter fruit. 



Medical News Letter, Vol. 32, No. 5 15 



In the Fourth Annual Report on venereal disease problems and prog- 
rams, it is contended that states, territories, and cities cite no substan- 
tial improvement in their programs over last year; a definite worsening 
of the venereal disease picture is claimed in selected areas for the country 
as a whole. This report was prepared by three national organizations and 
is based on separate reports from all 48 states, from 3 territories, and 
from 94 of the 109 cities in the United States with populations of 100,000 
or over. It was revealed that rates are rising statewide in 19 states, 
that control programs are inadequate in 35 states, that teenage venereal 
disease is increasing in 1 1 states, that new epidemiologic outbreaks are 
reported in 19 states, and that Armed Forces personnel, transient laborers, 
and other mobile groups are listed by 32 states and 15 city health officers 
as major problems in venereal disease control. 

Rein summarized the syphilis problenn of today. He stated that 
syphilis is on the rise again. A Public Health Report estimated that 
1,921,000 persons in the United States have syphilis requiring treatment. 
Many states and large cities find their venereal disease appropriations 
inadequate to permit an effective and progressive program. Of major con- 
cern, is the fact that high rates for primary, secondary, and early latent 
syphilis are in the age group of 15 to 19, reaching a peak at the 20-24-year 
group. Rapidly declining rates over the past several years have prompted 
the optimistic demobilization of venereal disease control forces, reassign- 
ments of personnel and reduction of case findings, and reduction of diagnostic 
and treatment facilities, leaving many areas without means to discover cases 
or to combat sudden outbreaks. (Beerman, H. , The Problem of Syphilis 
Today: Arch. Dermat. , 78^: 174-179, August 1958) 

^ ^ iff i!/: ijli iff 

Cancer of Rectum and Colon 

While great advances have been made in colonic surgery, there has 
been only slight improvement in the number of patients cured of cancer of 
the rectunn and colon. A reported 30, 000 individuals die annually from this 
disease. 

The authors believe that greater emphasis must be placed upon early 
detection of this disease while it is still localized to the bowel wall and is 
thus amenable to cure by the accepted radical surgical procedures. The 
frequency of malignant disease of the bowel is higher in people with a family 
history of intestinal malignancy and also in those who have already had car- 
cinoma of the bowel. Such persons should be observed carefully and period- 
ically for evidence of neoplasm of the bowel, even though symptonns of such 
disease are not present. It is equally important to detect and eradicate the 
precursor of cancer of the bowel — the adenomatous polyp. 



l6 Medical News Letter, Vol. 3Z, No. 5 



Generally, it is assumed that the end results for cancer in this organ 
are reasonably satisfactory. Keview of the literature, however, reveals a 
considerable discrepancy in reported figures, varying from 10 to 50% for 
5 -year survival rates. The national average probably is about 2Z%. This 
is the recorded future obtained from representative groups and persons 
collaborating for the Third National Cancer Conference in Detroit in 1956. 
The California Tumor Registry reports a 20% 5-year nonrecurrence rate. 
This means that only one patient in five is cured. Compared with the end 
results of treatment of cancer of other organs, this figure is not too unfavor- 
able. However, this average is well below the result that could be obtained 
if every facet of cancer control now available were utilized by all physicians. 

Numerous pathological studies — especially those by Dukes, and Gil- 
christ and David — have clearly shown that when the lesion is still localized 
to the bowel wall, the 5 -year survival rate is 80% or better. When, however, 
there has been extension beyond the bowel wall to the lyoiph nodes, this per- 
centage is reduced by half. Unfortunately, a nnajority of cases coming to 
surgery fall in the latter group. 

At present, there is an average delay of 9 months between the onset 
of symptoms and definitive surgery. Physicians and patients alike share 
the responsibility for this delay. Although many determining factors are 
involved, every effort should be made to avoid delay in the diagnosis of this 
disease because there is no predictable time when the individual lesion be- 
comes incurable. 

The authors suggest several ways in which carcinonna can be detected 
in an earlier stage. These suggestions are: periodic examinations of those 
over 40 years of age; bowel exannination when there is a family history of 
intestinal malignancy; lifetime follow-up on all patients with neoplasm of 
the bowel; and prompt and adequate exannination of all patients with rectal 
bleeding to establish the source. 

Periodic Examination of Those over Forty Years of Age . Most phys- 
icians are seeing an increased number of patients for an annual check-up 
examination. The nature of such an examination varies considerably with 
each physician and depends upon the time available and certain economic 
limitations. Routine proctoscopy in the absence of symptoms is seldonn 
carried out as part of such an examination, but this examination offers an 
\inusual opportunity to detect early cancer in an accessible organ that is 
frequently involved with this disease. Of equal significance is the oppor- 
tunity to discover and eradicate a precancerous lesion, that is, an adeno- 
matous polyp which is the precursor of most — if not all — intestinal cancers. 

Many studies have revealed an adenomatous polyp in about 10% of 
persons examined. A small percentage of such polyps already have devel- 
oped early malignancy and a very high percentage of such patients have been 
cured by accepted surgical procedures. Persons in whom proctoscopic 
examination reveals a polyp should undergo roentgenologic examination to 



Medical News Letter, Vol. 32, No. 5 17 



determine if there are polyps present in the abdominal colon. In the auth- 
ors' experience, such additional polyps have been found in one of six patients 
exannined. 

Bowel Examination when there is a Family History of Intestinal Malig- 
nancy. While generally accepted that human cancer is not inherited, exper- 
ience indicates that the incidence of malignant or premalignant neoplasm is 
considerably greater in those persons with a family history of intestinal 
cancer. 

It is suggested that all members of the immediate family of a patient 
with intestinal malignancy be examined for the possibility of an intestinal 
neoplasm being present and periodic observation continued, 

Lifetinne Follow-Up on All Patients with Bowel Neoplasm. Every 
patient who has had cancer of the bowel should have a lifetime follow-up 
because of the possibility of developing a second carcinoma; the chances 
are one in ten, which is 100 times greater than in the average adult. Real- 
ization of this increased potential should be an incentive to look for early 
asymptomatic carcinoma while it is still localized. Similarly, every pat- 
ient who has had a benign polyp should have a lifetime follow-up in order to 
detect others that might arise. Destruction of such lesions — when confined 
to the mucous membrane — is a relatively simple procedure and may avoid 
a far more radical operation. 

Prompt and Adequate Examination of All Patients with Rectal Bleeding 
to Establish the Source. It is especially true that the fate of such patients 
often rests with the first physician consulted. Too frequently, after exter- 
nal inspection and digital examination, the patient is falsely reassured until 
the further passage of time makes it obvious that further study is indicated. 
All patients with a history of having passed blood per rectum require sig- 
rnoidoscopy to detect a neoplasm beyond the reach of the finger as a source 
of bleeding. This is equally true even though bleeding is infrequent or 
trivial in amount. 

If no adequate explanation of bleeding is found, roentgenologic exam- 
ination of the abdominal colon is required. It should be unnecessary to 
remind any medical audience that a negative bariunn enema in no way rules 
out neoplasm in the rectum. Air contrast studies are unquestionably more 
satisfactory than ordinary opaque x-rays in detecting intraluminal polyps. 
All patients — if bleeding continues — are requested to return without pre- 
paration for repeat sigmioidoscopy to determine more accurately if bleed- 
ing is coming from beyond the reach of the proctoscope. When bleeding 
continues and can be demonstrated to be coming from a higher level, 
exploratory laparotomy is indicated in spite of repeated negative x-ray 
studies. The diagnostic accuracy of barium enema examination is not more 
than 90% for well established carcinoma and less accurate for adenomatous 
polyps. (Klein, R. R. , Scarborough, R.A. , Improving the End Results in 
Cancer of the Rectum and Colon: Am J. Surg., 96: 331-335, August 1958) 



IS Medical News Letter, Vol. 32, No. 5 

Early Exploration of Vascular Xniuries 

In this article, the importance of exploration of all penetrating wounds 
which occur in the vicinity of large vessels is ennphasized and evidence to 
support this point of view is presented. The cases are grouped in three 
categories. Those cases in which the major injured vessels were arteries 
are grouped as arterial injuries. Although frequently the accompanying 
veins were also injured, the arterial injury was considered the most signi- 
ficant. Grouped under venous injuries are those cases in which at explora- 
tion the major injury was to a large vein. In the third group of cases are 
those in v/hich exploration revealed no injury to either nnajor arteries or 
veins. 

From October 1948 to October 1954, only 17 explorations were carried 
out for suspected arterial or major venous injuries. In 1 1 of the 17 cases, 
exploration revealed significant injuries to arteries or large vessels. There 
were 15 cases of arteriovenous fistulas and traunnatic aneurysnns seen during 
this period. Emergency treatnnent was performed at this hospital (Homer 
G. Phillips Hospital, St. Louis) for the initial injury in 12 cases and surgical 
exploration in 1 case. Of the remaining 2 cases, no initial care was given 
in one and conservative treatment at another hospital in the other case. 

However, since 1954, 66 explorations have been carried out with sig- 
nificant injury to vessels found in 47 cases. Since 1954, there have been 
only 2 patients with arteriovenous fistulas and 1 with traumatic aneurysnn 
admitted to the surgical service — all of which resulted from lack of initiative 
on the part of the patient in seeking immediate attention. One presented 
himself 6 days after injury with a false aneurysm of the left anterior tibial 
artery. Another presented himself 7 years after having been treated con- 
servatively for a stab wound of the thigh. The third patient presented 
himself 25 hours after having sustained a gunshot wound of the elbow which 
resulted in an arteriovenous fistula and a false aneurysm of the brachial 
artery. Since 1954, the authors have not observed an arteriovenous fistula 
or a false aneurysnn resulting from injuries to vessels in individuals who 
presented themselves for early initial care. They believe that this is due to 
an insistence on exploration in all patients with evidence suggestive of major 
vessel injury. The eradication of arteriovenous fistula and false aneurysms 
resulting from trauma is an obtainable end. These serious complications can 
be markedly reduced or prevented by early exploration for potential vascular 
injuries. 

When indications are clear, there must be no hesitation in exploring 
systematically the areas involved. When indications are doubtful, every 
effort should be made to establish the presence or absence of vessel injury. 

The authors recommend that all penetrating woionds in the vicinity of 
great vessels be imnnediately explored or arteriograms performed to ex- 
clude arterial injury. It must be remembered, however, that negative arter- 
iograms do not exclude the presence of major venous injury. 



Medical News Letter, Vol. 32, No, 5 19 



Liigation of major vessels is undesirable and — when performed — may 
result in serious complications with subsequent major or minor disability. 

The immediate restoration of injured arteries by resection of dannaged 
areas and primary repair with simple suture or the use of autografts or homo- 
grafts, is stressed to achieve the beat results. 

Infections should be avoided if at all possible by aseptic technique and 
the use of antibiotic therapy. (Sinkler, V/.H., Spencer, A, D. , The Impor- 
tance of Early Exploration of Vascular Injuries: Surg. Gynec. & Obst. , 
107 : 228-234, August 1958) 

* * * o= sf: * 

Prosthetic Restorations Associated 
with Abnormal Jaw Relations 

Maxillomandibular relations which involve deviations from the normal 
occur with considerable frequency and often are associated with challenging 
diagnostic and treatment problems. These abnormal conditions nriay occur 
in such gross form as to be obvious innmediately or they may be so subtle 
that they defy detection against all but the closest scrutiny. Similarly, phys- 
iologic reaction to the abnormalities may range from complete absence of 
symptoms to conditions of such severity that pathologic conditions of the oral 
structures or temporomandibular joint are deinonstrable. 

Among the direct reactions attributed to the malrelationships are retro- 
grade periodontal processes and displacement of the condyles within the fossae. 
The latter condition has been claimed to produce such synaptoms as tenderness, 
crepitus, clicking, subluxation, pain, tinnitus, and dizzines s. Muscle ten- 
sions, deafness, and various reflex responses throughout the body are also 
said to result. 

Regardless of the nature of magnitude of the abnormality, all treatnnent 
procedures are based on the same fiondamental considerations of anatomy, 
physiology, and other sciences related to the chewing mechanism. Although 
many abnormal jaw relationship problems are treated successfully by gen- 
eral operative dentistry procedures, some require treatment within the 
specialties of dentistry. For instance, certain conditions which involve 
periodontal pathologic changes associated with traumatogenic occlusal dis- 
harmonies are treated best by the periodontist. When changes in tooth pos- 
itions are indicated, the orthodontist renders treatnnent most effectively. 
Occasionally, the correction of gross abnormalities may demand the talents 
of the oral surgeon. This article discusses certain situations which are of 
special concern in the field of prosthodontics. 

Although countless abnormal situations occur, a high percentage of the 
conditions which the prosthodontist is called on to treat fall into four groups 
which show the following typical relationships: 



ZO Medical News Letter, Vol. 32, No. 5 



1. Upward and backward displacement of the condyles due to cuspal 
disharmonies or loss of posterior tooth support, 

2. Acquired mandibular prognathism, usually with overclosure and 
such poor occlusion that there is no proper interdigitation of the posterior 
teeth. 

3. Deep anterior overbite due to overeruption of the anterior teeth. 

4. Deep anterior overbite due to undereruption of the posterior teeth. 
Various combinations of these conditions may occur and each may be 

associated with some degree of lateral displacement. Unusual situations 
are encountered occasionally, such as anterior and lateral displacement on 
one side with posterior and lateral displacement on the opposite side. 

In all instances, the condition should be analyzed in the manner sug- 
gested by Thompson and Craddock. 

vVhen the choice is available, fixed restorations are preferred to re- 
movable appliances because the fixed restorations reproduce tooth contours 
nnore naturally and minimize the hazard of caries. However, fixed restora- 
tions do not permit as wide dispersal of masticatory forces as do removable 
appliances with rigid connectors. This is particularly true where crowns 
are lengthened to increase the vertical dimension of occlusion. 

«V^hen removable prosthetic appliances are indicated for temporary or 
prolonged use, protective measures are required to prevent decalcification 
of the enamel, especially where overlays cover the teeth. Recontourixig of 
irregular tooth surfaces and preventive odontotomy may be indicated before 
final impressions are taken. The twice -yearly application of a suitable 
fluoride solution may be advantageous. Above all, patients must be in:^- 
pressed with the necessity for meticulous care of the teeth and appliances. 

The similarity of certain temporomandibular joint and malrelation- 
ship problems permits grouping for diagnostic and planning purposes. Cor- 
rective procedures, however, must be based on specific biologic and phys- 
ical requirements and limitations of the individual case. Treatment should 
be undertaken only when these factors are clearly understood. 

The objectives of treatment are attained largely through establishment 
of an occlusion which is in harmony with centric relation at a physiologically 
acceptable vertical dimension. (Frechette, A. R. , CAPT DC USN, Prosthe- 
tic Restorations Associated with Abnormal Jaw Relations: J. Am. Dent. A. , 
57 : 210-220, August 1958) 

****** 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget 19 June 1958. 

?|i ;^ :^ 5]c :^ 3jc 



Medical News Letter, Vol. 32, No. 5 21 



Parathyroid Crisis 

Sudden death from hyperparathyroidism is not common. It can be 
prevented. Just as thyroid storm is a fulminating increase in the manifes- 
tations of hyperthyroidism, the majority of instances of parathyroid crisis 
occur as acute exacerbations of chronic hyperparathyroidism. Two major 
factors have been suggested which precipitate a crisis: high calcium intake, 
as in an ulcer regimen where antacids containing absorbable calcium are 
used, and immobilization which increases the rate of skeletal denninerali- 
zation. The end result is an abnormal increase in serum, urinary calcium, 
and phosphorus followed by a rapid death. The mechanism of death is, pre- 
sumably, cardiac poisoning by calcium with cardiac arrest in systole. 

This disease is often misdiagnosed or overlooked completely, yet it 
can be diagnosed rather easily and a cure almost assured. A thorough under- 
standing of parathyroid crisis is necessary, therefore, if this disease is to 
be recognized and treated in time. 

The case presented is typical of the 22 previously reported instances 
of parathyroid crisis. In virtually all of the reported cases, an acute epi- 
sode was superimposed on chronic hyperparathyroidism evidenced by kidney 
stones or metastatic calcium deposits and bone changes. It is thought that 
kidney stones or calcium deposition may precede bone changes by several 
years. 

Eighty-six percent of the cases of hyperparathyroidism are due to 
functional adenomas. All but 3 of the 23 reported cases of parathyroid crisis 
were due to parathyroid adenomas. Of these 3 cases, 1 was caused by 
overdosage with parathyroid extract; another was due to a parathyroid car- 
cinoma; the third was reported as frank hyperplasia. Virtually all cases of 
parathyroid crisis, therefore, are due to adenomata; these usually are 
solitary. 

The acuteness of onset of symptoms is the one distinguishing clinical 
feature between parathyroid crisis and ordinary chronic hyperparathyroidism. 
The diagnosis, therefore, must evolve frona the same diagnostic criteria as 
apply to hyperparathyroidism in general. Vagueness of symptoms is char- 
acteristic of hyperparathyroid disease and often results in many overlooked 
or misdiagnosed cases. 

Pain is an almost constant feature of impending crisis. Fifteen of the 
23 cases had abdominal pain in varying degrees. This ranged from mild 
discomfort to the severe incapacitating type resembling renal colic or other 
acute abdominal disease. Chest pain and aches misinterpreted as cardiac, 
rheumatic, or arthritic in origin, are fairly common. In 14 recorded cases, 
bone pains were noted. Some of these pains were related to fractures; some 
to severe backache; others to exquisitely tender areas usually in long bones. 

Equally constant are the anorexia, nausea, and vomiting which are 
nnanife stations of this disease. Some additional clinical features may help 



22 Medical News Letter, Vol. 32, No. 5 



to identify this disease. Often, there is a disproportionately high pulse 
rate in spite of increasing drowsiness. This, plus high fevers of unknown 
etiology, was recorded in over 50% of the cases. Constipation was observed 
in one-third of the cases. "Band keratitis, " which Cogan describes as cal- 
cification in the superficial layers of the cornea, may be present. Also, 
calcium deposits in the conjunctivae and palpebral fissures are occasionally 
seen. Mental aberrations and even psychoses are fairly common findings 
and often mask the underlying disease. 

Undoubtedly, the next most important diagnostic feature after the phys- 
ician's high index of suspicion and diagnostic agility, is elevation of the 
serum calcium. A serum calcium of 17 mg. %, according to Albright, is the 
critical level above which the symptoms of parathyroid crisis may be expec- 
ted to ensue. At these exceptionally high levels of serum calcium, the serum 
inorganic phosphorus also tends to rise because it can no longer be excreted 
by the kidneys. This is an extremely grave prognostic sign and immediate 
measures should be taken to reduce the serum calcium. Albright describes 
the danger signals of parathyroid crisis as rising serum calcium, phosphorus, 
and NPN levels, and a sharp fall in urine volume. Because an elevated urine 
calcium accompanies hypercalcemia, a good easy preliminary examination 
is the Sulkowitch test which is always positive in hypercalcinuria. If the 
patient is in parathyroid crisis, the serum analysis will enable the physician 
to make definite diagnosis. 

Surgical extirpation is the treatment of choice at the present time. Six 
of 23 cases were completely relieved when the parathyroid adenoma was 
removed. As most of the patients in parathyroid crisis are dehydrated, 
James and Richards suggest hydration with isotonic saline before surgery to 
minimize hypochloremia. They also recommend that pressor agents be given 
to prevent shock preoperatively. The use of chelating agents may prove effec- 
tive by a transient lowering of the serum calcium to maintain the patient dur- 
ing the ennergency period until surgery can be performed with safety. Agents, 
such as edathamil are under experimental study, but severe internal hemor- 
rhages and renal tubular necrosis have hampered their extensive use to date. 
{Hewson, J. S, , Parathyroid Crisis: Arch. Int. Med., 102 : 199-203, August 
1958) 

*t »t sjc ric rfc dr 

Treatment of Idiopathic Thrombocytopenic Purpura 

Ninety-three patients (28 males, 65 females), in whom the diagnosis 
of idiopathic thrombocytopenic purpura was satisfactorily established, form 
the basis of this article. Patients with thrombocytopenia associated with 
other hematological disorders or portal hypertension, or following the use 



Medical News Letter, Vol. 32, No. 5 23 



of drugs or other substances known to produce platelet deficiency, have been 
excluded. 

All patients had hemorrhagic manifestations and less than 100,000 
platelets per c. mm. of blood on at least two occasions. Eighty-five patients 
had a prolonged bleeding -time, and of 70 in whom it was estimated, 58 had 
an increased capillary fragility. Smears of bone marrow were examined in 
44 cases. In all, the number of megakaryocytes was normal or increased 
and no abnormality of the red cells or white cells was seen. In no case, 
was the spleen palpable; the weight of spleens removed surgically ranged 
from 50 g. to 230 g. (average 120 g. , which is within the limits of normal). 

Idiopathic thrombocytopenic purpura may present without previous 
warning as an episode of mild or nnoderate bleeding into the skin and from 
mucous membranes or as an illness which is serious either because of the 
degree of blood loss or — as in intracranial hemorrhage— because the site of 
bleeding is particularly dangerous. It is recognized that even when no speci- 
fic treatment is given, spontaneous recovery can occur. However, serious 
symptoms may supervene even in mild cases at any time and especially in 
the first few days of the disease. Four patients in the present series had 
intracranial hemorrhage and died within two days of first being seen. The 
results of steroid therapy in the short-history cases suggest that these drugs 
do no more than facilitate the natural tendency of this disease to spontaneous 
remission and possibly accelerate its onset. Evidence about the place of 
splenectomy in the severely ill patient with a short history is equivocal. 

On the other hand, there is convincing evidence of the beneficial 
effect of splenectomy once the acute hemorrhagic phase has passed. Symp- 
toms were immediately relieved, the bleeding-time was shortened, and the 
platelet count rose in 13 of the 14 patients of whom full records were kept. 
Improvement persisted in at least 75% of cases followed up for more than 
12 years after operation. 

Results suggest that the initial management of the patient with a short 
history of purpura should be blood transfusion to replace any serious blood 
loss and administration of cortisone (75 mg. every 6 hours) or prednisolone 
(15 mg. every 6 hours) for 3 weeks. If the platelet count rises during this 
time, there is a very good chance that it will be maintained. If there is no 
improvement within 3 weeks, splenectomy should be performed in the ex- 
pectation that at this time it will be followed by a good result in 75% of the 
cases. The authors adduced no evidence to show that the patient in the acute 
hemorrhagic phase is benefited by splenectomy. 

Patients with a long history of relapsing purpura should also be given 
a 3 -week course of steroid therapy. About half of all patients improved 
during, or shortly after, treatment, but it is evidently exceptional for any 
such remission to last for more than 60 days. Therefore, it seems that 
all such patients should be submitted to splenectomy either during the steroid- 
induced remission or as soon as it is apparent that the treatment has failed 



24 . Medical News Letter, Vol. 32, No. 5 



to influence the platelet count. However, when a remission does occur, it 
it may be justifiable to defer operation in milder cases, especially if it is 
a response to the first course of steroid treatment. Delay in these circum- 
stances is probably harmless, provided the patient is able to report frequent- 
ly for hematological examination so that the innpending relapse can be anti- 
cipated and a further course of steroid therapy given as a preliminary to 
splenectomy. The chances of a permanent remission following splenectonny 
in this group of patients — although less than in those with a short history- 
were still in the region of 50% up to 20 years after operation. 

The management of the patient who continues to have severe symptoms 
after splenectomy is difficult. Long continued treatment with cortisone 
(75-100 mg. per day) or prednisolone (10-15 mg. per day) was given to five 
such patients in this series (and in higher doses to another operated on more 
recently) without any significant improvement in platelet counts or in the 
severity of symptoms. In contrast to these results, 2 of 4 patients who had 
failed to respond to splenectomy were treated by the Medical Research 
Council Hematology Panel (1955) with cortisone (50-100 mg. daily) for more 
than 6 nnonths and were maintained in remission for that time. The details 
of these cases were not given and it may be that the two who were maintained 
had short histories and might, therefore, have remained well once a rennis- 
sion had been obtained. Among other reports in the literature, the authors 
failed to find an example of a patient with a long history of purpura having 
had a steroid-induced remission lasting more than 2 months. 

The results of steroid therapy in patients who relapsed after splenec- 
tomy suggest that, if there is going to be improvement, it will be evident 
within 3 or 4 weeks of the start of treatment and will almost certainly not 
be maintained for much more than 2 months. If the platelet count has not 
risen within this time, it is unlikely to do so with further continuous treat- 
ment, no matter how intense or how long continued. It is better to stop 
treatment, accepting any minor clinical improvement that may have occurred, 
and to start another course should bleeding recur. Whenever a minor opera- 
tion or dental extraction is necessary in a patient with a persistently low 
platelet count after splenectomy, it should be covered by a course of pred- 
nisolone starting 4 or 5 days before operation and lasting not less than 10 days. 
(Watson- vVilliams, E. J. , Macpherson, A. I. S. , Sir Stanley Davidson, The 
Treatment of Idiopathic Thronnbocytopemc Purpura - A Review of Ninety- 
Three Cases: The Lancet, Vol. _2 for 1958: 221-226, 2 August 1958) 

:^ 4: # ^ ^ ^ 

Policy 

The U. S. Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 



Medical News Letter, Vol. 32, No. 5 25 



items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged to 
obtain the original of those items of particular interest to the individual. 

rfr ^ ?{c ife ife A 

Hazards in the Handling of Hydrogen Peroxide 

According to the Hygienic Guide published by the American Industrial 
Hygiene Association, the maximum 8 -hour exposure to 90% hydrogen per- 
oxide is one part per million of vapor or mist per million parts of air by 
volume. However, it is believed that further industrial experience is needed 
to confirm this figure. 

Hydrogen peroxide, 90%, the present standard commercial concentra- 
tion, is a liquid at room temperature that is essentially odorless, but it can 
produce sharp respiratory irritation. 

vVhile health hazard through inhalation is moderate, skin and eye con- 
tact with the liquid produces severe reaction. It causes skin to become 
thickened, and bleaching and loss of hair occurs. Skin or eye contact with 
the liquid will produce tissue destruction, but the eyes do not appear to be 
damaged from exposure to the vapor. 

Although the liquid does not have a fire hazard if kept out of contact 
with combustible material, it can ignite nearby flamnnable material. 

Special procedures are required for storage and handling of 90% hydro- 
gen peroxide. Workmen should wear protective clothing. Garments — both 
outer and inner — made of woven dacron fabric are eminently suitable. Dynel 
or saran fabrics are also usable. Impermeable aprons and the like may be 
made of polyvinyl chloride or polyethylene film. Gloves and boots should 
be made of either nitrile rubber, vinyl resin or Neoprene. 

Goggles should be worn at all tinnes when handling concentrated hydro- 
gen peroxide. In case of spillage, the spot should be flushed immediately 
with water. If this flushing is done in time, it will prevent any vigorous 
reaction. Water is also the best extinguishing agent for fires that may re- 
sult from spillage. 

Hydrogen peroxide is used industrially in high energy fuels, as an 
organic oxidant bleaching agent, and in lesser concentration for pharma- 
ceutical preparations. (Hazards in the Handling of Hydrogen Peroxide: 
Air Gond. Heat. & Vent., 54: 71, November 1957) (OccMedDispDiv, BuMed) 

****** 



26 Medical News Letter, Vol. 32, No. 5 



Occupational Aspects of Habituating Drugs 

There is convincing evidence from clinical experience that any nervous 
system depressant or stimulant can be classified as a habituating drug. Addic- 
tion involves two distinct clinical problems: dependence on chemicals rather 
than on latent resources, and physiological changes resulting from the toxic 
effects of the chennical. Alcohol presents by far the most serious problem; 
next in order are the sedatives and tranquilizers. Most addicts to barbitu- 
rates and tranquilizers were fornnerly addicted to alcohol. Narcotics pres- 
ent a minor problem. Addiction to the nervous system stimulants also occurs 
to an unknown extent. The estimated loss to industry from alcoholism is one 
billion dollars annually; 1% of this sum could well be spent by industry for 
research on problems connected with alcoholism and drug addiction. 

Attempts to place the whole responsibility for the excessive use of 
nervous system depressants on the alcoholic beverage industries are only 
indicative of ignorance of the over all problem and the futile attempts, thus 
far, to cope with it. VVhen basic research into addiction is in keeping with 
the size of the problem, then — and then only — will be the time for positive 
action leading to educational programs and clinical procedures which can 
institute prevention. (Bell, R. G. , Problems Resulting from the Use of 
Habituating Drugs in Industry - The Problenr] within Industry: Am. J. Pub. 
Health, 48_: 585-589, May 1958; abstracted in Indust. Hyg. Digest, 22:11, 
June 1958) (OccMedDispDiv, BuMed) 

1^ ^ :}: jjc :{c :^ 

Mouth -to -Mouth Versus Manual 
Artificial Respiration 

Detailed comparative studies of mouth -to -mouth breathing and manual 
artificial respiration have been performed on temporarily apneic, uncon- 
scious infants, small children, and adults. 

Mouth-to-miouth breathing assures adequate ventilation in all cases, 
v'/ith the manual push-pull methods and manual rocking, complete obstruc- 
tion of the airway has occurred in a significant number of subjects and 
piartial airway obstruction was noted in all of the other cases. 

The single most important factor in assuring adequacy of ventilation 
is proper extension of the neck and elevation of the jaw. The most useful 
technique for performing mouth-to-mouth breathing in infants and small 
children involves a specific series of actions. This is also true of the best 
techniques for performing direct mouth -to -mouth and mouth-to-nose resus- 
citation of adults. (Gordon, A. S. , et al. , Mouth-to -Mouth Versus Manual 
Artificial Respiration for Children and Adults: J. A. M. A. , 167: 320-328, 
May 17, 1958) 

A sk -Ste ris jfe ste 



Medical News Letter, Vol. 32, No. 5 27 

Atypical Heat Stroke 

Three fatal cases of atypical heat stroke which occurred in unseasoned 
recruits who started training during summer months at a military installa- 
tion near San Antonio, Texas, are described. 

Instead of the dramatically abrupt onset of cerebral symptoms assoc- 
iated with a rectal temperature of 106° F. or above which is the typical pic- 
ture of heat stroke, the cases studied by these authors exhibited gradual 
onset of symptoms over periods up to four days and at no time did the body 
temperature exceed 106° F. When first seen at sick call, the presenting 
symptoms were those of mild heat illness and the cases were treated as out- 
patients with fluids and salt tablets. 

On return visits from several hours up to three days, changes in be- 
havior were noted. These were characterized by combativeness, confusion, 
and disorientation. Two were initially hospitalized with psychiatric diagnoses 
before the underlying disorder became evident. In all three cases, the dom- 
inating clinical picture soon after admission was that of circulatory shock 
associated with failure of renal function. Although hyperthermia of moderate 
degree (101°, lOZ. 6°; and 106° F. ) was noted soon after admission in each 
case, therapy was directed principally toward restoring adequate circulation. 
To this end, intravenous fluids, including plasma expanders and whole blood, 
were given together with vasopressor agents and hydrocortisone. Attempts 
to reduce body temperature were limited to alcohol sponging and fanning. 
This type of treatment proved ineffective and hyperthermia of varying degree 
persisted until the end. In two cases, recurrent shock and persistent oli- 
guria characterized the clinical course. In one case, the blood pressure 
was restored and well maintained, but renal function did not recover. 

Serious disorders of salt, water, and acid-base balance were evident 
fronr: blood studies on the first hospital day, which revealed markedly deplet- 
ed alkali reserve. On the second hospital day, serum potassium and non- 
protein nitrogen began to rise with further decrease in available base. 
Associated with the hyperkalemia were ECG signs of potassium intoxication. 

In an attempt to reduce the concentration of circulating potassium, 
hemodialysis was employed in two cases and administration of cation- 
exchange resin by rectum in the third. 

Restitution of the nornnal blood electrolyte pattern was only partially 
achieved by these measures and this partial recovery was temporary. On the 
third hospital day, hyperkalemia of even more marked degree was again pres- 
ent (9. 5, 8. 5, and 6.9 mEq/L.). Associated clinical signs of potassium intox- 
ication recurred. Acidosis became severe. Emergency measures to prolong 
survival were unsuccessful, two cases dying during the third hospital day and 
the remaining case on the fourth day. The most significant pathological find- 
ing revealed during autopsy was that of renal tubular degeneration with the 
distal tubules filled with casts. 



28 Medical News Letter, Vol. 32, No. 5 



In analyzing these cases, the authors emphasize the importance which 
the uncorrected hyperthermia played as a contributing factor in the fulmina- 
ting potassium intoxication which they consider as the immediate cause of 
death. Cellular damage from hypoxia associated with shock and potassium 
loss from cells resulting from severe acidosis were related causes of the 
rapid rise in serum potassium concentration observed on the second and 
third hospital day. 

The authors conclude that efforts to restore adequate circulation and 
kidney function by fluid replacement are relatively ineffective in the presence 
of persistent hyperthermia. Moreover, use of vasopressor agents are contra- 
indicated in heat stroke because these interfere with dissipation of body heat. 

Finally, in preventing atypical heat stroke, all cases of mild heat ill- 
ness which fail to respond to usual therapy within 24 hours should be hos- 
pitalized for careful study of thermoregulatory mechanisms, circulation, 
and water and electrolyte balance. (Baxter, C. H. , Teschan, F, E. , Atypical 
Heat Stroke with Hypernatremia, Acute Renal Failure, and Fulminating Po- 
tassium Intoxication: Arch. Indust. Med,, 101; 1040-1050, June 1958) 
(Thermal Stress Branch, OccMedDispDiv, BuMed) 

9JC ^ Sk Sf? ^ l4c 

NewT Film Release 

The Bureau of Medicine and Surgery announces the release of a new 
official training film entitled Color Vision Deficiency: Definition and Eval - 
uation (MN-8246) which will be of immediate interest to all Medical Depart- 
ment personnel who are concerned with color perception in the military 
service. 

This 16-mm. film is 20 minutes long, has both narration and dialogue, 
and is in color. Its main objective is to give an understanding of color vision 
and the importance of color discrimination in the military services. The 
picture offers answers to the following questions: vVhat constitutes an ade- 
quate degree of color perception for special military jobs? What is the 
difference in the vision of color-deficient persons known as protans and 
deutans? vVhat colors are actually confused by persons with each type of 
color-vision deficiency? What are the practical limitations and consequences 
of defective color perception? 

The film uses some striking devices to accomplish its purpose. A 
"color map" prepared especially for this production defines the kinds of color 
deficiency and demonstrates the colors that are confused by each type of 
color-deficient person. A sequence of scenes in a vividly decorated room 
demonstrates the degrees of color deficiency in a manner that is at once 
practical and dramatic. Then the film shows the military application of 
these facts: how, for example, the different degrees of deficiency can affect 



Medical News Letter, Vol. 32, No, 5 29 



a man's ability to distinguish between port and starboard running lights; 
and how a mild, moderate, or severe deficiency can variously affect a corps- 
man's ability to differentiate microorganisms in laboratory examination. 

In addition to the information just described, the film demonstrates 
the two methods used by the Navy for color- vision testing: the use of pseudo- 
isochromatic plates, and of the Farnsworth Lantern. Operators show in 
detail how to set up and light the area for each test and how to administer, 
score, and record. 

It is expected that medical officers^ will find this film most useful 
in preparing personnel-selection officers, hospital corpsmen, and all others 
charged with examination and assignnnent of personnel on the basis of color- 
vision tests. 

CDR Dean Farnsworth MSC USN, inventor of the Farnsworth Lantern, 
and Miss Helen Paulson, both of the Naval Medical Research Laboratory at 
New London, served as associate technical advisors on this project. Mr, 
John Verges, also of NMRL, prepared much of the original art work. Per- 
sonnel of the U. S. Naval Submarine Base at New London, the U. S. Naval 
Shipyard and the Receiving Station at Brooklyn, N. Y. , Floyd Bennett Air 
Base, N. Y. , and the U. S. Naval Hospital, St. Albans, Long Island, N. Y, , 
performed as members of the cast. Special acknowledgment is due to Mr. 
Ralph Evans, head of the Color Control Department of Eastman Kodak Com- 
pany, Rochester, N. Y. , for research and development of the technique 
used in showing the various degrees of color- vision deficiency. 

Prints are being distributed to Naval Hospitals, Hospital Corps Schools, 
special naval medical schools, District Training Aids Sections and Libraries, 
Naval Aviation libraries and Marine Corps training film libraries. If a print 
is not available from your usual source, address inquiry to the Film Distri- 
bution Unit, Training Division, Bureau of Naval Personnel, Departnnent of 
the Navy, Washington 25, D. C. (Audio-Visual Training, BuMed) 

V 'V^ 'i^ 'r -^ V 

From the Note Book 

1. Attention All Hands: Readers of the News Letter are again reminded 
that the items printed, except those obviously official, reflect the opinions 
and beliefs of the author or authors and do not reflect the opinion or attitude 
of the Bureau of Medicine and Surgery or the Department of the Navy. 

Editor 

2. The Bureau of Medicine and Surgery celebrated its ll6th anniversary 
on August 31, 1958, the only Bureau which still retains its original name 
as established by Congress in 1842. The history and traditions of the Navy 
Medical Department, however, began with the history of our country. Since 



30 Medical News Letter, Vol. 32, No. 5 



the days of the first Surgeons and Surgeon's Mates in the Colonial Navy, 
116 years ago, the Medical Department and its personnel have achieved a 
history of which they can be justly proud. Through improved techniques, 
equipment, supplies and facilities, personnel, training qualifications, and 
organization, their record of improving and maintaining the health of the 
Navy and of the Nation is one of continued progress. (TIO, BuMed) 

3. An Armed Forces Institute of Pathology exhibit depicting the role of the 
Armed Services in the fight against tropical diseases will be shown in Lisbon, 
Portugal, at the Sixth International Congresses on Tropical Medicine and 
Malaria, 5-13 September 1958. The exhibit, "Contributions of the United 
States Armed Services to the Control of Tropical Disease, " consists of four 
panels of photographs, charts, maps, and color transparencies. (A. F, I. P. ) 

4. The significance of tetanus in the U. S. today is presented. Between 500 
and 600 people die each year of the disease. A plea is made for much greater 
use of tetanus toxoid in active immunization to prevent the needless loss of 
time and life from either the disease or a now outmoded nnethod of prophy- 
laxis against the disease. (Surg. Gynec. & Obst., August 1958; C. D. Sherman, Jr. 
M, D. , D.H. Barnhouse, M. D. ) 

5. Proper diagnosis is extremely important when dentures are planned and 
posterior occlusion determined. The responsibility for denture planning 
belongs to the dentist alone. A denture is more than a piece of hardware; 
it will always need to be a physiological restoration. (J. A. D. A. , August 
1958; S.H. Payne, D. D. S. ) 

6. In a 7-year period in a community hospital, 153 patients with upper 
gastrointestinal bleeding were hospitalized and treated. Of these, 143 were 
classified as bleeding ulcer. This group was divided into 82 cases of proved 
ulcer, 34 of presumed ulcer, and 27 of suspected \ilcer. These cases have 
been subjected to statistical analysis and the authors' preference in the man- 
agement of this type of case is presented. (Arch. Surg. , August 1958; J. P. 
Chandler, M. D. , R. R. Santos, M. D. ) 

7. The anesthetic problems and management of 200 patients who have under- 
gone cardiopulmonary bypass for intracardiac surgery, using low flow per- 
fusion with a bubble oxygenator, are reviewed. (Anesthesiology, July - 
August 1958; A. S. Keats, M. D. , et al) 

8. Wegener's granulomatosis is an uncommon syndrome in which giant-cell 
granulomata in the respiratory tract occur together with granulomatous and 
vascular lesions resembling those in polyarteritis nodosa. This article, based 
on a study of 10 cases and 46 others selected from the literature, describes 



Medical News Letter, Vol. 32, No. 5 31 



and tabulates the clinical and pathological features (Brit. M. J, , Z August 
1958; E.W. Walton, M. D. ) 

9. Two surgical approaches to the popliteal artery, the medial and the 
posterior, are described. The posterior approach has its greatest applica- 
bility in the surgical treatment of popliteal aneurysms. (Am. J. Surg. , 
August 1958; F. M. Binkley, M. D., E.J. Wylie, M. D. ) 

10, Arteriography in neoplasms of the extremities is discussed in Am. J. 
Roentgenol., August 1958; A. R. Margulis, M.D., T.O. Murphy, M. D. 

****** 

BUMED INSTRUCTION 6230. 8C 31 July 1958 

From: Chief, Bureau of Medicine and Surgery 
To: All Ships and Stations 

Subj: Poliomyelitis vaccine; use of 

Ref: (a) BuMedlnst 6230. lA, Subj: Immunization requirements and 
procedures 
(b) BuMedlnst 6310.4, Subj : Morbidity Report, NavMed- 1390 (Med- 
6310-2); and Special Epidemiological Reports (Med-6200-2 (Notal) 

This instruction promulgates Department of Defense policy and revises instruc- 
tions in regard to the use of poliomyelitis vaccine. BuMed Instruction 6230. 8B 
is canceled. 

• ****** 

BUMED INSTRUCTION 6250. 6 6 August 1958 

From: Chief, Bureau of Medicine and Surgery 
To: Naval Hospitals and Medical Centers 

Subj: Pest control at naval hospitals 

Ref: (a) BuMedlnst 6250, 5, Subj: Insect and rodent control 

(b) BuMedlnst 6250.4, Subj: Pest control; vector and economic 

End: (1) Guidelines for Pest Control in Naval Hospitals 

This instruction provides guidelines for the effective control of insects, 
rodents, and other pests at naval hospitals. 



32 Medical News Letter, Vol. 32, No. 5 




DEMTAl IkW^I SECTI01\ 



NDS Short Graduate Courses 1958 - 1959 

The U. S. Naval Dental School, National Naval Medical Center, Beth- 
esda, Md. , will present a series of fourteen short postgraduate and refresh- 
er courses in nine Subjects to career Dental officers of the Armed Forces 
during Fiscal Year 1959. This is the second series of short courses to be 
presented by the Dental School in the program initiated in 1957, Details 
regarding quotas and eligibility will be published at a later date. Courses 
to be presented and schedules are: 

Courses Dates 

Endodontics Oct 13-17, 1958 Oct 20-24, 1958 

Oral Surgery Nov 17-21, 1958 Apr 13-17, 1959 

Oral Pathology Dec 1-5, 1958 Mar 9-13, 1959 

Partial Dentures Jan 12-16, 1959 -- 

Periodontics Mar 2-6, 1959 May 4-8, 1959 

High Speed Orientation Mar 16-20, 1959 Apr 27 - May 1, 1959 

Casualty Care Apr 13-17, 1959 

Crown and Bridge Apr 20-24, 1959 

Complete Dentures May 18-22, 1959 

Training in Casualty Treatment 

During Fiscal Year 1958, the training of dental personnel in casualty 
treatment procedures was conducted at the U.S. Naval Dental School, National 
Naval Medical Center, Bethesda, Md. ; U.S. Naval Dental Clinic, Naval Base, 
Norfolk, Va. ; and U. S. Naval Training Centers at San Diego, Calif. , Great 
Lakes, 111., and Bainbridge, Md. Approximately three hundred Navy Dental 
officers completed this course during this period. In addition, the U. S. 
Naval Dental Clinic, Norfolk, Va. , trained approximately two hundred and 
fifty other personnel in conjunction with the Navy-wide First Aid and Self 
Aid Program. Instructors of the Navy Dental Clinic also assisted in the 
Disaster First Aid Program in the junior and senior high schools of Norfolk 



Medical News Letter, Vol. 32, No. 5 33 



by demonstrating the casualty treatment manikin and other aids before four- 
teen thousand boys and girls during a 2 -week period. 

:{: 9}: jjc :^ ^ »[c 

BuMed Notice 6620 - Dental Appointment Card 

This notice advises that a dental appointment card has been standar- 
dized and described as "Dental Appointment, NavMed 1379. " The new 
appointment form will be used in lieu of the various types of dental appoint- 
n:ient card now being used throughout the Navy and Marine Corps. 

36s iSc A A sfc sic 




RESERVE SECTIOIVI 

Credit for Attending Professional Meeting 

The American Academy of Dermatology and Syphilology will conduct 
its 17th annual meeting at the Palmer House, Chicago, 111. , during 6-11 
December 1958. The Chief of Naval Personnel has authorized one (1) retire- 
ment point credit to eligible inactive Naval Reserve Medical Corps officers 
for daily attendance, provided they register daily with the military represen- 
tative present. 

3^ ^ >]c :ijc :{e 3(c 

Available Naval War College Publication 

Inactive Naval Reserve Medical Department officers, LCDR and above, 
not on the Inactive Status List, are eligible to receive, gratis, the Naval 
v'/ar College Review upon individual request addressed to: 

Head, Correspondence Courses Department 
Naval War College 
Newport, Rhode Island 
The Naval vVar College Review was established in 1948 under the title, 
"Information Service for Officers. " The present title was assumed in 1952. 
The purpose is to publish for the benefit of officers of the Armed Forces 
selected material that has been presented to resident students of the Naval 
War College. It is published in 10 issues per academic year, comnnencing 
in September and ending in June. 



34 Medical News Letter, Vol. 3Z, No. 5 



In making application, Reservists should include their grade, service 
and designator, and include the statement, "eligible in accordance with 
category (b) of paragraph 5, BuPers Instruction 1552. 5A;" also add whether 
the subscription is new or a renewal. Subscriptions are effective for one 
academic year only and those desiring renewal must resubscribe by using 
the printed form that is available in each year's June issue. 

Note: To insure receipt of early issues, applications should reach the Naval 
A'ar College as soon as possible. 

Sjc ;SC 5jc si! ^ ^ 

Special Pay Scale for Certain Junior Officers 

The new military pay law provides that connmissioned officers in the 
grades of ENS (0-1), LTJG (0-2), and LT (0-3) who have been credited with 
more than four years' active service as enlisted members will have their 
basic pay computed on a special pay table. If you qualify under this pro- 
vision, here's what you should do: 

If you are currently associated with a Naval Reserve Program in a 
pay status, notify your commanding officer immediately — in writing — 
that you claim miore than four years' active enlisted service. Your CO 
will then take all the necessary follow-up action. 

When you request active duty for training (AcDuTra) with pay, be sure 
to include in your request a statement that you claim more than four years' 
active enlisted service. 

If you are not in either category, you need take no action until you 
become associated in a pay status with a Naval Reserve Program or request 
AcDuTra with pay. At that time, proceed as outlined above. (The Naval 
Reservist, July 1958) 

:{{:{! sj; ^ :{t j^ 

Medical Symposia in Special Weapons 

Two 4-day courses in the medical aspects of atomic weapons' effects 
are scheduled for presentation at the Field Command, Armed Forces 
Special Weapons Project, Sandia Base, Albuquerque, N. M. , during the 
periods 3-7 Nov 1958 and 16-20 Mar 1959. 

The courses are intended to present the latest information on special 
weapons and the oiedical effects on man and material. 

Eligible are: Senior inactive Naval Reserve Medical Corps officers 
whose probable mobilization assignnnent would be to a fleet staff or major 
base in the theater of operation. Quotas have been allocated to Commandants 



Medical News Letter, Vol. 32, No. 5 35 



of the Eighth, Ninth, Eleventh and Twelfth Naval Districts. TOP SECRET 
security clearance is required and nominations from Commandants must 
reach the Bureau of Medicine and Surgery (Code 362) at least 60 days in 
advance of the convening dates. 

^ >^ :{c :{; 3[e :f: 



^^^^ PREVENTIVE MEDICIIVE SECTION 



Foods in Vending Machines 

The brave new world of prepackaged food, hot meals from coin- 
operated vending machines, and other mechanical approaches to the storage 
and distribution of human nutriment is here. Health officials must evaluate 
the possible bearing of these developments upon nutrition and sanitation with 
a view to encouraging favorable developments and preventing those that may 
have unfavorable effects on health. 

\^here operators of processing plants beconne conscious of their res- 
ponsibility to protect the consumer's health, there is increased incentive 
for competing suppliers of packaging materials and machines to consider 
sanitation and health protection. 

Improvements in methods of vending foods have been greatly innple- 
mented by improved packaging as well as by improved sanitation in con- 
tainers and mechanisms for vending foods and drinks. Health officials who 
admit concern over the handling of foods in public eating and drinking estab- 
lishments should be equally concerned not only about the dispensing mech- 
anisms — whether manually or coin operated — but over the sanitary safeguards 
established in the preparation, handling, and storage of the food or drink to 
be vended. 

A considerable interest in the possible health and sanitation hazards 
in this field was created by work of the Subcommittee on Food Sanitation of 
the Committee on Sanitary Engineering and Environment, National Research 
Council, and by investigations started some years ago under sponsorship of 
the Armed Forces Epidemiological Board. More recently, the Armed Forces 
placed responsibility upon the manufacturer desiring to place machines in 
canteens to present satisfactory evidence of the successful testing of each 



36 Medical News Letter, Vol. 32, No. 5 



device in a disinterested and nationally recognized laboratory. Much test- 
ing has been done by the National Sanitation Foundation Testing Laboratory, 
and some coin-operated vending machines now are available that bear its 
seal of approval as evidence of compliance with good practices in sanitation. 
Other laboratories are reported to be doing similar testing. 

The Public Health Service also has worked with the industry in estab- 
lishing a recommended code for coin-operated vending machines. Com- 
pliance with the requirements of this code is being used by the National 
Sanitation Foundation Testing Laboratory as one of the necessary require- 
ments for approval. 

With the evaluation of new machines by sanitarians before they are 
placed in production, the employment of well .trained men to service the 
machines, and occasional inspection by health department field men, food- 
vending machines can be operated satisfactorily. (Tiedennan, W.D. , 
Implications of New Developments in Food and Milk Processing, Packaging, 
Storing, and Vending: Am. J. Pub. Health, 48: 854-860, July 1958) 

^ ijc 3|c :}: :Jc ^ 

Revision of International Travel 
Immunization Information 

Immunization Information for International Travel, the Public Health 
Service Publication No. 384, June 1956, which is under complete revision 
by the Foreign Quarantine Division, Public Health Service, Departnnent of 
Health, Education, and Welfare, is expected to be released by 1 September 
1958. This revision will incorporate the Supplement, February 1957 and 
all changes made in Public Health Service and international imnnunization 
requirennents and the designated yellow fever vaccination centers since 
June 1956. Medical officers having a 1956 edition of this booklet may obtain 
revised copies by letter request to the Bureau of Medicine and Surgery 
(Attention: Code 72) or from the local Public Health Service office. 

The International Certificates of Vaccination, PHS 731, as approved by 
the World Health Organization, were revised in January 1957 to include the 
changes made in the Section, "International Certificate of Vaccination or 
Revaccination against Smallpox, " at the 9th World Health Organization Assem- 
bly, 1956. This certificate is used only for dependents and civilians travel- 
ing overseas under Armed Forces cognizance in accordance with BuMed 
Instruction 6230. lA, Immunization Requirements and Procedures, and is 
valid when certified by a military medical officer or Public Health Service 
officer, and when it carries the approved official seal or stamp of the Depart- 
ment of Defense or Public Health Service, 

Although this new certificate has been issued to Navy supply depots, it 
has been brought to the attention of the Bureau of Medicine and Surgery that 



Medical News Letter, Vol. 3Z, No. 5 37 



individuals appear with the old certificate, PHS 731 {Revised 1952), which 
is no longer valid except when the vaccinations recorded thereon have not 
reached the expiration date. (Communicable Disease Branch, PrevMedDiv, 
BuMed) 

* :^ * * * * 

Recent Advances in the Study of Venereal Diseases 

The Ninth Annual Symposium on Recent Advances in the Study of Ven- 
ereal Diseases and the Venereal Disease Control Seminar for Public Health 
Regions I, II, and V, sponsored by Public Health Service, Department of 
Health, Education, and Welfare, was held in Philadelphia, Pa., 12-15 May 
1958. Articles were presented on both the clinical and laboratory aspects 
of syphilis and gonorrhea. The following summary report was submitted 
by LT William E. Carson MC USN, U. S. Naval Hospital, Philadlephia, who 
attended these meetings as representative of the Bureau of Medicine and 
Surgery. 

Although much research is being done on syphilis and gonorrhea, 
better methods of diagnosis and treatment are needed. The greatest 
diagnostic problem lies in differentiating latent syphilis from biologic 
false positive reaction. While there is no serologic test that is specific 
for diagnosing syphilis, the treponemal tests are of great value. The 
Reiter Protein Complement Fixation Test (RPCF) holds promise of be- 
coming a fairly inexpensive test with a moderate degree of sensitivity 
and specificity. The Treponenna Pallidum Complement Fixation Test 
(TPCF) may be used as a screening test utilizing the technically more 
difficult Treponema Pallidum Immobilization Test (TPI) when the result 
of the TPCF is inconclusive. Although the TPI is less sensitive, it has 
a greater degree of specificity and is the test by which other treponemal 
tests are compared. 

Because of the increasing problem of sensitivity to penicillin, various 
broad spectrum antibiotics have been used in the treatment of syphilis. 
Erythromycin, in a total dose of 10 gm. , was used in one small series, 
but the follow-up was too short for adequate evaluation. In another study, 
carbomycin was used in a total dose of 21 gm. given over a period of 10 
days; the 5-year follow-up studies showed good results. Other broad 
spectrum antibiotics in comparable dosage schedules have been used with 
good results, but penicillin still remains the drug of choice in treating 
syphilis. 

Gonorrhea is a very important problem in the venereal disease picture. 
Studies with fluorescein-labelled antibodies indicate that this laboratory 
method may be of value in the future in the diagnosis of gonorrhea. 



38 Medical News Letter, Vol. 32, No. 5 



Accurate diagnosis is exceedingly difficult, especially in the female. 
Treatment of the acute disease in the male is easily accomplished by 
relatively small doses of antibiotics, but this is not so in the female. To 
increase the cure rate and reduce the number of reinfections, antibiotic 
quarantine has been established by the public health departments of sev- 
eral venereal disease clinics. A single injection is given with a mixture 
of 600, 000 units of aqueous procaine penicillin G plus 1, 2 nmillion units of 
benzathine penicillin G which provides protection against reinfection for 
8 weeks. The addition of 600, 000 units of aqueous procaine penicillin G 
is superior to 1. 2 million units of benzathine penicillin G alone; dihydro- 
streptomycin in doses of 1 gm. daily gives excellent results in acute 
gonorrhea; the sulfa drugs — particularly some of the newer ones — are of 
value in treating acute gonorrhea; and all broad spectrun] antibiotics are 
effective. 

:{c :{( ^ ^ :[: :{; 

Pulmonary Diseases Associated with 
Atypical Acid-Fast Bacilli 

Atypical acid-fast bacilli are being reported more frequently in diag- 
nostic microbiology. The ultimate classification and significance of these 
organisms is still to be determined, therefore, a coordinated investigation 
of the problem is indicated. 

Traditionally, in diagnostic microbiology the acid-fast bacilli have 
been classified as either pathogens or saprophytes. However, with more 
general use of culture procedures, there have been an increasing number of 
cases yielding acid-fast bacilli which had neither the typical characteristics 
of the known pathogens nor of the rapidly growing saprophytes. This group 
of unclassified bacilli has been given the temporary descriptive designation 
of atypical acid-fast bacilli pending agreement on definitive classification 
and appropriate designation. 

During two years of research (1955-1957), through consolidated efforts 
of tuberculosis hospital, bacteriological and clinical laboratories, and public 
health laboratories in Florida, atypical acid-fast bacilli were isolated from 
108 individuals with pulmonary disease; 36 were found in the first year, 72 
in the second. During the second year, the first isolation from 22 of the 
cases was from sputum specimens submitted to public health laboratories; 
others were found through examination in a clinical pathological laboratory. 

Early in this study, these organisms were identified in only one labora- 
tory. As the characteristics of these agents became known to other labora- 
tory workers, the extent of detection increased, suggesting a beginning 
discovery rather than a beginning occurrence. Some of the organisms now 
identified as atypical acid-fast bacilli were reported heretofore in part as 



Medical News Letter, Vol. 32, No. 5 39 



M. tuberculosis and in part dismissed as unimportant saprophytes — actions 
which need to be avoided in view of accumulating knowledge. It is not evi- 
dent to what extent the increasing detection of these infections represents a 
true increase in their occurrence. 

The usual observations on cultures for acid-fast bacilli were not ade- 
quate to readily identify these atypical organisnns, however, all grew at 
room temperature, thus differentiating them from M. tuberculosis. Three 
types of atypical strains, photochromogens, nonphotochromogens, and scoto- 
chromogens can be identified on the basis of light conditioned and nonlight 
conditioned pigment fornnation. 

The simplest supplementary test was the catalase reaction. Of 75 
atypical strains isolated from hospitalized patients, there was a strongly 
positive catalase reaction in 72. Only in three was there a weak reaction 
which would correspond to the reaction given by H37Kv strain of M. tuber- 
culosis. 

Prior to the initiation of chemotherapy in individual cases, M. tuber- 
culosis with few exceptions was found by in vitro tests to be susceptible to 
streptomycin, para-amino salicylic acid (PAS), and isoniazid. In contrast, 
most of the atypical strains under study were highly or partially resistant 
to PAS and isoniazid, although somewhat more susceptible to streptomycin. 
Recent in vitro tests of 20 atypical strains against promine, streptovaracin, 
and cycloserine were more encouraging. 

In this 2-year period in which there was a progressive increase in the 
technical reliability in the detection of these atypical organisms, they were 
fotuid in 87 hospitalized cases. This represents approximately 3% of all 
hospitalized patients. Based on total admissions, the approximate propor- 
tion of cases found positive in white males was 6%, in white females 3%, in 
Negro patients 1%. 

There were no clinical findings in these cases to differentiate from 
infections due to M. tuberculosis. The history and physical and radiological 
findings in patients from whom only atypical acid-fast organisms were iso- 
lated repeatedly were those of tuberculosis. These atypical organisms were 
foTond chiefly in those with moderately or far advanced disease. 

The tuberculin skin test (Intermediate purified protein derivative) (PPD) 
was negative in one-fifth of the patients tested. Tests using a crude tuber- 
culin prepared from atypical mycobacteriae were tried, but with no conclu- 
sive finding. 

The most striking clinical feature of these cases was the lack of favor- 
able response to the standard antituberculosis drug therapy. Approximately 
half of the cases failed to have any favorable response to drug therapy as 
indicated by radiological changes. In vitro susceptibility tests support the 
clinical observations that other than the standard antituberculosis drug 
therapy needs to be tried in these infections. 

No longer is it permissible to assume that acid-fast bacilli isolated from 
the sputum or gastric contents of suspected cases of tuberculosis may be 

«U. S. GOVERNMENT PRINTING OFFICE ; 1958 O - 481^ 



40 



Medical News Letter, Vol. 32, No, 5 



expected to be either M, tuberculosis or saprophytes. Current evidence 
indicates that between these familiar organisms there is a spectrum of acid- 
fast bacilli which may range from active human pathogens to harmless sapro- 
phytes. Of these, the photochromogens are acknowledged to be more highly 
pathogenic for man than they were found to be for mice. The scotochromes 
at the opposite extrenne are the least pathogenic. The nonphotochromes vary 
in their pathogenicity for mice and presumably also for man. In the current 
state of limited knowledge, all these organisms need to be regarded with 
suspicion, particularly when isolated repeatedly and excreted in substantial 
numbers. Future studies must elucidate the factors in the host as well as 
differences in the type of the organism involved which determine the nature 
of the host-parasite relationships. 

These findings call for long-range coordinated studies involving bac- 
teriologists, epidemiologists, and clinicians. Further, the detailed nature 
of the required bacteriological examinations makes it desirable in the interest 
of efficiency and reliability to refer all suspected organisms to a specialized 
laboratory for detailed study. (Hardy, A. V. , et al, Bacteriological and 
Epidemiological Studies of Pulmonary Diseases Associated with Atypical Acid- 
Fast Bacilli: Am J. Pub. Health, 48: 754-759, June 1958) 

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